| NPI | 1538272976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MO 2002001967) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2002031815) |
| 122300000X Dentist (Licence: TX 19069) | |
| 208600000X Surgery (Licence: MO 2002001967) | |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MO 2002031815) | |
| Enumeration Date | 2006-08-17 |
| Last Update Date | 2016-06-02 |