| NPI | 1992797641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: ID D1753OS) |
| Additional Taxonomies | 174400000X Specialist (Licence: ID M4194) |
| Enumeration Date | 2005-08-18 |
| Last Update Date | 2007-07-09 |