| NPI | 1417104589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401412962) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 10265) |
| Enumeration Date | 2008-08-20 |
| Last Update Date | 2022-10-19 |