| NPI | 1174015887 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857947) |
| Enumeration Date | 2018-05-30 |
| Last Update Date | 2018-10-30 |