| NPI | 1073818217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ME DEN4547) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1855573) |
| 122300000X Dentist (Licence: NH 04685) | |
| Enumeration Date | 2011-01-19 |
| Last Update Date | 2026-03-23 |