| NPI | 1578629606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2003011293) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MO 2003011293) | |
| 1223X2210X Dentist, Orofacial Pain (Licence: MO 2003011293) | |
| Enumeration Date | 2007-01-01 |
| Last Update Date | 2024-09-05 |