| NPI | 1306491261 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: VA 0438000506) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401419061) |
| Enumeration Date | 2019-08-07 |
| Last Update Date | 2025-01-06 |