| NPI | 1760843767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX T8582) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 32597) |
| Enumeration Date | 2016-03-18 |
| Last Update Date | 2023-02-15 |