| NPI | 1124172531 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA 18417) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NH 3372) |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2017-03-22 |