| NPI | 1780722017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MA 20034) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 049683) |
| Enumeration Date | 2007-02-01 |
| Last Update Date | 2018-04-14 |