| NPI | 1376565580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: LA 5630) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: LA 5630) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2021-11-15 |