| NPI | 1316954670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: AK MedS7783) |
| Additional Taxonomies | 122300000X Dentist (Licence: AK 1136) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2015-10-05 |