| NPI | 1720090517 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WV 2578) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: WV 78) |
| Enumeration Date | 2006-08-12 |
| Last Update Date | 2012-05-15 |