| NPI | 1174903660 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1856894) |
| Additional Taxonomies | 122300000X Dentist (Licence: RI DEN03363) |
| Enumeration Date | 2015-06-01 |
| Last Update Date | 2018-01-02 |