| NPI | 1861453961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 27508) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MA 21380) |
| Enumeration Date | 2006-03-29 |
| Last Update Date | 2012-02-01 |