| NPI | 1740282748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX F1680) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 9602) |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2011-01-06 |