| NPI | 1750506598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 16961) |
| Additional Taxonomies | 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: TX 16961) |
| Enumeration Date | 2007-04-16 |
| Last Update Date | 2021-01-04 |