| NPI | 1710324066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: FL DRP1308) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA 6374) |
| Enumeration Date | 2013-05-28 |
| Last Update Date | 2014-06-30 |