| NPI | 1750475224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207ZP0102X Pathology Anatomic Pathology & Clinical Pathology (Licence: TX 20680) |
| Additional Taxonomies | 1223P0106X Dentist Oral and Maxillofacial Pathology (Licence: TX 20680) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 20680) | |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2024-09-26 |