| NPI | 1659314888 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MI 2901022525) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: ND 1946) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2022-07-21 |