| NPI | 1366952897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1857790) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 12164) |
| Enumeration Date | 2017-10-11 |
| Last Update Date | 2024-06-27 |