| NPI | 1639153430 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: SC 4120) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 4120) |
| Enumeration Date | 2005-12-05 |
| Last Update Date | 2018-03-26 |