| NPI | 1023685179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MA DL14755) |
| Additional Taxonomies | 1223E0200X Dentist Endodontics (Licence: MA DL14755) |
| Enumeration Date | 2021-06-08 |
| Last Update Date | 2021-07-01 |