| NPI | 1689781189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: UT 1453789924) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: UT 1453788903) |
| Enumeration Date | 2006-08-23 |
| Last Update Date | 2010-11-16 |