| NPI | 1861874760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: OR MD204165) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D10069) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OR D10069) | |
| Enumeration Date | 2015-06-26 |
| Last Update Date | 2021-04-29 |