| NPI | 1609468636 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MN 80282) | 
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MN D14527) | 
| Enumeration Date | 2021-02-10 | 
| Last Update Date | 2025-09-25 |