| NPI | 1740698257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MO 2020008265) |
| Additional Taxonomies | 122300000X Dentist (Licence: DC DEN1001396) |
| Enumeration Date | 2014-07-28 |
| Last Update Date | 2023-05-22 |