| NPI | 1124158589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: RI 02543) |
| Additional Taxonomies | 1223P0106X Dentist Oral and Maxillofacial Pathology (Licence: RI 02543) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: RI 02543) | |
| 332B00000X Durable Medical Equipment & Medical Supplies | |
| Enumeration Date | 2007-03-06 |
| Last Update Date | 2019-12-17 |