| NPI | 1306629290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ME den5378) |
| Additional Taxonomies | 124Q00000X Dental Hygienist (Licence: FL 25736) |
| 122300000X Dentist (Licence: NH 05206) | |
| 1223P0300X Dentist, Periodontics (Licence: MA DL100711) | |
| Enumeration Date | 2023-08-15 |
| Last Update Date | 2026-07-15 |