| NPI | 1265682686 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: SC 826) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 4466) |
| 1223P0300X Dentist Periodontics (Licence: MA DN1855503) | |
| Enumeration Date | 2008-09-22 |
| Last Update Date | 2015-06-04 |