| NPI | 1639376049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 26386) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: OK DDS5976) |
| Enumeration Date | 2007-06-29 |
| Last Update Date | 2016-03-31 |