| NPI | 1376938522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: CA 197411) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040613) |
| Enumeration Date | 2015-04-04 |
| Last Update Date | 2024-10-14 |