| NPI | 1720241615 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: ND 2085) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 57097) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: MN D12849) | |
| Enumeration Date | 2008-07-09 |
| Last Update Date | 2011-12-29 |