| NPI | 1679521660 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 30633) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS036394) |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2022-06-20 |