| NPI | 1053704619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: PA RFD000031) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MA DF11032) |
| Enumeration Date | 2015-03-06 |
| Last Update Date | 2021-04-19 |