| NPI | 1518917343 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: KY 29938) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KY 5901) |
| Enumeration Date | 2006-05-11 |
| Last Update Date | 2008-02-14 |