| NPI | 1134746464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NC 12463) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1858766) |
| Enumeration Date | 2020-07-02 |
| Last Update Date | 2023-06-04 |