| NPI | 1649214164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OH 30-023253) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2004012411) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: OH 096558) | |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2016-12-13 |