| NPI | 1770983355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC 00216) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857193) |
| 122300000X Dentist (Licence: ME DEN4397) | |
| Enumeration Date | 2014-09-02 |
| Last Update Date | 2020-07-20 |