| NPI | 1629320353 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 27458) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: TX 0) |
| Enumeration Date | 2012-10-04 |
| Last Update Date | 2017-04-09 |