| NPI | 1720320252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: SD D1298) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 30492) |
| Enumeration Date | 2013-03-22 |
| Last Update Date | 2023-02-06 |