| NPI | 1154495364 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA 15842) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS026162L) |
| Enumeration Date | 2006-11-20 |
| Last Update Date | 2007-07-08 |