| NPI | 1689795114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: UT 6434136-1205) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: UT 6434136-9925) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: NE 6395) | |
| Enumeration Date | 2007-04-02 |
| Last Update Date | 2021-11-01 |