| NPI | 1447561485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 10404) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 10404) |
| 122300000X Dentist (Licence: NY 056482) | |
| 122300000X Dentist (Licence: MA DN1855394) | |
| Enumeration Date | 2010-06-24 |
| Last Update Date | 2015-09-29 |