| NPI | 1780894170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 0023735) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: LA S-355) |
| Enumeration Date | 2007-05-23 |
| Last Update Date | 2010-01-04 |