| NPI | 1740577592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: LA 7046) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60226297) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 32707) | |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2024-07-28 |