| NPI | 1619168556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OH 30-023817) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 23462) |
| Enumeration Date | 2007-08-06 |
| Last Update Date | 2015-03-17 |