| NPI | 1336302363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: SC 7125) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 8500) |
| Enumeration Date | 2008-07-09 |
| Last Update Date | 2013-06-15 |