| NPI | 1386052116 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MN D13395) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13395) |
| Enumeration Date | 2014-07-24 |
| Last Update Date | 2022-06-03 |