| NPI | 1356570824 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: AZ TBD) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WV 3916) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NM DD446) | |
| 204E00000X Oral & Maxillofacial Surgery (Licence: AZ TBD) | |
| Enumeration Date | 2009-07-06 |
| Last Update Date | 2020-07-02 |