| NPI | 1568605731 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: OR MD173704) | 
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OR D9277) | 
| Enumeration Date | 2009-04-16 | 
| Last Update Date | 2025-07-17 |