| NPI | 1487973061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MD 16265) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 30761) |
| Enumeration Date | 2010-05-22 |
| Last Update Date | 2019-12-11 |