| NPI | 1912360553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WI 1001323) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1001323-15) |
| Enumeration Date | 2016-03-31 |
| Last Update Date | 2022-07-15 |