| NPI | 1790933414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: CO DEN.00204287) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 73742909922) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA DDS100908) | |
| Enumeration Date | 2008-09-05 |
| Last Update Date | 2020-10-30 |