| NPI | 1851371025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CO 9735) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY P44870) |
| 122300000X Dentist (Licence: TX 20788) | |
| 1223G0001X Dentist, General Practice (Licence: NY P44870) | |
| 204E00000X Oral & Maxillofacial Surgery (Licence: TX 20788) | |
| Enumeration Date | 2006-01-22 |
| Last Update Date | 2011-08-12 |