| NPI | 1336303874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 23871) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: TX 233871) |
| Enumeration Date | 2008-07-14 |
| Last Update Date | 2025-03-03 |