| NPI | 1659728061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PR 3420) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 060843) |
| 122300000X Dentist (Licence: OH 30025184) | |
| Enumeration Date | 2016-05-16 |
| Last Update Date | 2023-02-28 |