| NPI | 1982864492 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: PA MD452026) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 10137) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: PA DS039854) | |
| Enumeration Date | 2008-06-10 |
| Last Update Date | 2020-10-01 |