| NPI | 1487997813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX 29150) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 29150) |
| Enumeration Date | 2013-04-04 |
| Last Update Date | 2022-10-19 |