| NPI | 1407208853 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: FL DTP690) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL12969) |
| Enumeration Date | 2016-07-11 |
| Last Update Date | 2021-01-20 |