| NPI | 1740458389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: PA MD449368) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.022637) |
| Enumeration Date | 2008-02-18 |
| Last Update Date | 2020-10-02 |