| NPI | 1700848827 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: SC 4453 772 OS) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TN 7629) |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2013-02-12 |