| NPI | 1790849834 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MO MO GEN #011763) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: MO MO SPEC #00483) |
| Enumeration Date | 2006-12-21 |
| Last Update Date | 2007-07-08 |