| NPI | 1790209484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 33309) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 33309) |
| Enumeration Date | 2017-08-03 |
| Last Update Date | 2024-07-02 |