| NPI | 1306224266 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: DC DEN2000518) | 
| Additional Taxonomies | 122300000X Dentist (Licence: NC 11356) | 
| 122300000X Dentist (Licence: VA 0401415370) | |
| Enumeration Date | 2015-05-12 | 
| Last Update Date | 2025-07-11 |