| NPI | 1013352863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 30291) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856252) |
| Enumeration Date | 2013-05-07 |
| Last Update Date | 2021-05-27 |