| NPI | 1053179325 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN10000555) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DEN100623) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2024-03-11 |
| Last Update Date | 2025-01-02 |