| NPI | 1558451914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MA 13487) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: NH 10451) |
| Enumeration Date | 2006-10-13 |
| Last Update Date | 2007-07-08 |