| NPI | 1306830971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MA DN19960) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NY 000013-2) |
| Enumeration Date | 2005-09-09 |
| Last Update Date | 2022-07-21 |