| NPI | 1508005984 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: PR 2758) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 053129) |
| Enumeration Date | 2009-02-09 |
| Last Update Date | 2011-12-01 |