| NPI | 1346227766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN11460) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 004227) |
| 122300000X Dentist (Licence: CA 39735) | |
| 122300000X Dentist (Licence: VA 0401007806) | |
| Enumeration Date | 2005-12-28 |
| Last Update Date | 2007-07-08 |