| NPI | 1457672958 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: GA 053375) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: GA DN013859) |
| Enumeration Date | 2010-06-18 |
| Last Update Date | 2019-07-22 |