| NPI | 1861605487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: OR md28928) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 21510) |
| Enumeration Date | 2007-05-08 |
| Last Update Date | 2009-06-02 |