| NPI | 1346613312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MI 2901601967) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MA DN1857103) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MI 2901601967) | |
| Enumeration Date | 2015-11-12 |
| Last Update Date | 2023-11-14 |