| NPI | 1265975312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 33470) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DL12935) |
| Enumeration Date | 2016-11-22 |
| Last Update Date | 2017-09-21 |