| NPI | 1578884912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OR D10206) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2010016152) |
| Enumeration Date | 2010-06-21 |
| Last Update Date | 2025-09-15 |