| NPI | 1982637922 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: OH 21379) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: OH 79671) |
| Enumeration Date | 2006-07-09 |
| Last Update Date | 2014-01-09 |