| NPI | 1760604177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MI 2901010019) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: AZ 2211) |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2007-07-08 |