| NPI | 1407063662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 25891) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: KS 60549) |
| Enumeration Date | 2007-05-17 |
| Last Update Date | 2011-03-25 |