| NPI | 1740656313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: AZ 12395) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: TX 37111) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: OR 10331) | |
| Enumeration Date | 2015-08-18 |
| Last Update Date | 2025-09-04 |