| NPI | 1952652802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC 9413) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 28455) |
| Enumeration Date | 2012-10-01 |
| Last Update Date | 2019-02-20 |