| NPI | 1154531689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN22109) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 50-053192) |
| Enumeration Date | 2007-05-23 |
| Last Update Date | 2015-08-11 |