| NPI | 1003163619 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1855978) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1855978) |
| Enumeration Date | 2012-08-14 |
| Last Update Date | 2020-04-29 |