| NPI | 1063870483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1859541) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: VT 016.0134389) |
| 122300000X Dentist (Licence: CA 100962) | |
| 1223P0300X Dentist, Periodontics (Licence: CT 14635) | |
| Enumeration Date | 2016-01-29 |
| Last Update Date | 2025-12-08 |