| NPI | 1780648576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 3273) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: SC 474) |
| Enumeration Date | 2006-04-17 |
| Last Update Date | 2007-07-09 |