| NPI | 1194070649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 10815) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1856098) |
| Enumeration Date | 2012-07-20 |
| Last Update Date | 2012-07-20 |