| NPI | 1366671281 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CT 11114) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: NY 056650) |
| Enumeration Date | 2009-07-13 |
| Last Update Date | 2018-04-18 |