| NPI | 1902004526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: VA 0401414741) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WV 3767) |
| Enumeration Date | 2007-07-05 |
| Last Update Date | 2019-01-11 |