| NPI | 1376084004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1857694) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 100882) |
| Enumeration Date | 2017-03-14 |
| Last Update Date | 2018-01-05 |