| NPI | 1619436425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MN D14380) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 1002257-15) |
| Enumeration Date | 2019-03-19 |
| Last Update Date | 2020-06-23 |