| NPI | 1952909087 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 39012) | 
| Additional Taxonomies | 122300000X Dentist (Licence: CA 105615) | 
| 1223G0001X Dentist, General Practice (Licence: TX 39012) | |
| Enumeration Date | 2020-10-12 | 
| Last Update Date | 2025-08-12 |