| NPI | 1154866770 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 11066) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857483) |
| Enumeration Date | 2017-01-05 |
| Last Update Date | 2024-09-25 |