| NPI | 1932368701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2022018797) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 39391) |
| Enumeration Date | 2008-06-05 |
| Last Update Date | 2023-06-20 |