| NPI | 1609213156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: FL ME171087) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: FL DN29808) |
| Enumeration Date | 2013-05-23 |
| Last Update Date | 2026-06-09 |