| NPI | 1720311442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE.60280647) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA MD.602817188) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: TX M6467) | |
| Enumeration Date | 2009-09-14 |
| Last Update Date | 2025-03-03 |