| NPI | 1659650828 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: UT 8046391-9921) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 8046391-9921) |
| Enumeration Date | 2011-08-05 |
| Last Update Date | 2016-08-24 |