| NPI | 1578525671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KY 8122) |
| Additional Taxonomies | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: TX 33929) |
| 171000000X Military Health Care Provider (Licence: TX 33929) | |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2021-10-31 |