| NPI | 1366925356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1859198) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 12515) |
| Enumeration Date | 2018-09-14 |
| Last Update Date | 2022-01-24 |