| NPI | 1316204696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX V8027) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 38311) |
| Enumeration Date | 2012-04-11 |
| Last Update Date | 2025-04-22 |