| NPI | 1497789036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MO 2005019138) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MO 2005019138) |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2016-09-30 |