| NPI | 1710411525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 064142-01) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: OK 236) |
| 208600000X Surgery (Licence: OK 40017) | |
| Enumeration Date | 2017-04-18 |
| Last Update Date | 2025-02-04 |