| NPI | 1295265015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DL13612) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DL13247) |
| 126800000X Dental Assistant (Licence: MA DA06547) | |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2019-01-10 |