| NPI | 1609869049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: AZ 12096) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: AZ 2656) |
| Enumeration Date | 2005-08-30 |
| Last Update Date | 2017-11-09 |