| NPI | 1396738746 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: LA 12434R) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MD 9545) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NH 2503) | |
| Enumeration Date | 2005-08-31 |
| Last Update Date | 2015-09-29 |