| NPI | 1750346656 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 30284) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: PA DS035833) |
| Enumeration Date | 2006-04-20 |
| Last Update Date | 2021-12-10 |