| NPI | 1407003650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: AZ d010233) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 57471) |
| Enumeration Date | 2008-08-19 |
| Last Update Date | 2019-11-26 |