| NPI | 1639514672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: OR 10645) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: AZ BD6377712-1392) |
| Enumeration Date | 2013-05-03 |
| Last Update Date | 2018-06-26 |