| NPI | 1821082744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: IA 06530) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: WI 3616015) |
| Enumeration Date | 2005-09-07 |
| Last Update Date | 2007-07-08 |