| NPI | 1972006914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: MI 2901601232) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: IL temporary) |
| Enumeration Date | 2018-03-15 |
| Last Update Date | 2022-10-20 |