| NPI | 1053645663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1855162) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS037925) |
| Enumeration Date | 2009-09-29 |
| Last Update Date | 2009-09-29 |