| NPI | 1407214752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1857137) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN015039) |
| Enumeration Date | 2016-02-02 |
| Last Update Date | 2016-03-22 |