| NPI | 1417155409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC 9867) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901019599) |
| Enumeration Date | 2007-07-11 |
| Last Update Date | 2016-03-31 |