| NPI | 1356402077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OR D5962) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MI 2901014309) |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2015-03-09 |