| NPI | 1619083565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MA 227532) |
| Additional Taxonomies | 122300000X Dentist (Licence: NH 04324) |
| 122300000X Dentist (Licence: VT 016.0002228) | |
| 204E00000X Oral & Maxillofacial Surgery (Licence: NH 18361) | |
| Enumeration Date | 2006-08-22 |
| Last Update Date | 2022-07-21 |