| NPI | 1780930545 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NM DD4263) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: FL DRP948) |
| Enumeration Date | 2012-07-31 |
| Last Update Date | 2017-12-24 |