| NPI | 1316252836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA 60829600) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901020267) |
| Enumeration Date | 2010-08-09 |
| Last Update Date | 2018-05-15 |