| NPI | 1679093603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: NC 2026-00045) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MD 16449) |
| 208600000X Surgery (Licence: MD D0096480) | |
| Enumeration Date | 2017-06-21 |
| Last Update Date | 2026-06-05 |