| NPI | 1972941292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CA 57935) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MT201468) |
| Enumeration Date | 2013-06-09 |
| Last Update Date | 2015-09-02 |