| NPI | 1083621585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MA D13019) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MA 13019) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2020-08-03 |