| NPI | 1720497001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC 12645) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 7173) |
| Enumeration Date | 2014-08-12 |
| Last Update Date | 2026-05-01 |