| NPI | 1467548560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: PA DS017502L) |
| Additional Taxonomies | 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: AZ az1704) |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2010-05-17 |