| NPI | 1922623834 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MN R760) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 38912) |
| Enumeration Date | 2020-06-16 |
| Last Update Date | 2022-08-25 |