| NPI | 1215272380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 28664) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MA DL11769) |
| Enumeration Date | 2012-11-30 |
| Last Update Date | 2016-04-18 |