| NPI | 1336414283 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1856170) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 27763) |
| Enumeration Date | 2012-03-11 |
| Last Update Date | 2014-07-28 |