| NPI | 1811288384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: AZ D010104) |
| Additional Taxonomies | 1223X2210X Dentist, Orofacial Pain (Licence: AZ D010104) |
| 125Q00000X Oral Medicinist (Licence: AZ D010104) | |
| Enumeration Date | 2011-05-02 |
| Last Update Date | 2019-10-03 |