| NPI | 1811506736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 39309) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2020023398) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MO 2020023398) | |
| Enumeration Date | 2020-07-27 |
| Last Update Date | 2023-03-12 |