| NPI | 1669638185 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QS0112X Clinic/Center, Oral and Maxillofacial Surgery (Licence: VA 0101277440) |
| Additional Taxonomies | 261QM2500X Clinic/Center, Medical Specialty (Licence: MD D0090703) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 24131) | |
| Enumeration Date | 2008-08-04 |
| Last Update Date | 2023-11-15 |