| NPI | 1063649267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MA DN1855283) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: ME PENDING) |
| 122300000X Dentist (Licence: MA DN1855283) | |
| Enumeration Date | 2009-06-15 |
| Last Update Date | 2010-04-28 |