| NPI | 1306629290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MA DL100711) |
| Additional Taxonomies | 122300000X Dentist (Licence: NH 05206) |
| 124Q00000X Dental Hygienist (Licence: FL 25736) | |
| Enumeration Date | 2023-08-15 |
| Last Update Date | 2025-08-13 |