| NPI | 1265923460 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1858801) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 12466) |
| Enumeration Date | 2018-05-23 |
| Last Update Date | 2021-07-19 |