| NPI | 1164086153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ME DEN4706) |
| Additional Taxonomies | 122300000X Dentist (Licence: ME DEN4706) |
| Enumeration Date | 2019-04-25 |
| Last Update Date | 2019-06-05 |