| NPI | 1366176810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: PR 003469) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1859554) |
| Enumeration Date | 2022-07-11 |
| Last Update Date | 2025-07-14 |