| NPI | 1376809129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 1001229-15) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL11594) |
| Enumeration Date | 2012-04-05 |
| Last Update Date | 2017-01-23 |