| NPI | 1376983908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DL12333) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401414551) |
| 1223D0001X Dentist, Dental Public Health (Licence: VA 0401414551) | |
| Enumeration Date | 2013-06-27 |
| Last Update Date | 2015-06-02 |