| NPI | 1093966673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1855593) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MA 10398) |
| Enumeration Date | 2008-10-01 |
| Last Update Date | 2014-04-28 |