| NPI | 1609229103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TN 10250) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: TN 10250) |
| Enumeration Date | 2016-07-20 |
| Last Update Date | 2026-07-05 |