| NPI | 1366158792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1859811) |
| Additional Taxonomies | 261QS1000X Clinic/Center, Student Health |
| Enumeration Date | 2023-01-30 |
| Last Update Date | 2025-05-29 |