| NPI | 1871682906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MA DN1855919) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 4214) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2014-07-06 |