| NPI | 1053974295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1858595) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS042320) |
| Enumeration Date | 2019-04-14 |
| Last Update Date | 2023-09-28 |