| NPI | 1871823963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX N8147) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: LA 5505) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 25178) | |
| Enumeration Date | 2010-01-12 |
| Last Update Date | 2019-04-30 |