| NPI | 1912104654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE60195746) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OK DDS5960) |
| Enumeration Date | 2007-06-27 |
| Last Update Date | 2011-06-20 |