| NPI | 1902965635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CO DENTAL 7167) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: CO MEDICAL 37605) |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2007-07-08 |