| NPI | 1225629942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ME DEN4831) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 36433) |
| 122300000X Dentist (Licence: ME FDN20) | |
| Enumeration Date | 2021-01-27 |
| Last Update Date | 2021-10-04 |