| NPI | 1902169014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: NC 2017-01221) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC 150890) |
| Enumeration Date | 2012-06-22 |
| Last Update Date | 2022-05-04 |