| NPI | 1629268966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: OR D9737) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2007019263) |
| Enumeration Date | 2007-08-01 |
| Last Update Date | 2021-06-08 |