| NPI | 1083023113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: MA DN1857536) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX ETN286) |
| 1223P0300X Dentist Periodontics (Licence: FL DN20632) | |
| Enumeration Date | 2014-08-02 |
| Last Update Date | 2017-04-13 |