| NPI | 1528028040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 19965) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX M0195) |
| Enumeration Date | 2006-03-27 |
| Last Update Date | 2010-12-13 |