| NPI | 1790086957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OR D11405) |
| Additional Taxonomies | 122300000X Dentist (Licence: AK 1364) |
| Enumeration Date | 2010-11-04 |
| Last Update Date | 2021-04-02 |