| NPI | 1386058584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 33281) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: GA DN015732) |
| Enumeration Date | 2014-06-16 |
| Last Update Date | 2025-08-29 |