| NPI | 1265961478 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 34887) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857884) |
| 122300000X Dentist (Licence: CT 12153) | |
| Enumeration Date | 2017-06-09 |
| Last Update Date | 2019-12-02 |