| NPI | 1528261682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 9675) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: OH 2403) |
| Enumeration Date | 2007-06-07 |
| Last Update Date | 2012-03-14 |