| NPI | 1629460951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 28914) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NM DD3892) |
| Enumeration Date | 2015-02-24 |
| Last Update Date | 2021-01-07 |