| NPI | 1306155411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MA DN1855921) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL11022) |
| Enumeration Date | 2010-10-07 |
| Last Update Date | 2014-08-11 |