| NPI | 1881034304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: OH 30025715) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 150944) |
| Enumeration Date | 2013-06-28 |
| Last Update Date | 2019-05-23 |