| NPI | 1386876282 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA 4758) |
| Additional Taxonomies | 126900000X Dental Laboratory Technician (Licence: IA 123639) |
| 152W00000X Optometrist (Licence: RI ODTG00564) | |
| 152W00000X Optometrist (Licence: NH 0859) | |
| Enumeration Date | 2009-08-12 |
| Last Update Date | 2024-01-09 |