| NPI | 1205179421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1856767) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D9790) |
| 122300000X Dentist (Licence: FL DN 19965) | |
| Enumeration Date | 2013-04-05 |
| Last Update Date | 2016-08-19 |