| NPI | 1114266947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1857350) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: NY 057695) |
| Enumeration Date | 2013-02-14 |
| Last Update Date | 2022-10-31 |