| NPI | 1083054001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1856566) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DL11949) |
| Enumeration Date | 2013-07-05 |
| Last Update Date | 2014-07-02 |