| NPI | 1396311718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MA DN1859184) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: GA DN122807) | |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: GA DN122807) | |
| Enumeration Date | 2021-05-27 |
| Last Update Date | 2023-10-03 |