| NPI | 1124499785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1857444) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1001215) |
| Enumeration Date | 2015-10-08 |
| Last Update Date | 2016-09-24 |