| NPI | 1912141177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401415174) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040240) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: NY P69524) | |
| Enumeration Date | 2009-04-30 |
| Last Update Date | 2023-04-11 |