| NPI | 1356040158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1859728) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 14177) |
| 122300000X Dentist (Licence: VT 16.0134268) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-03-01 |
| Last Update Date | 2024-07-26 |