| NPI | 1386164754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: ID D-5334-OS) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2017018304) |
| Enumeration Date | 2017-06-26 |
| Last Update Date | 2022-07-27 |