| NPI | 1457784407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1856646) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX ETN192) |
| Enumeration Date | 2013-08-14 |
| Last Update Date | 2016-05-09 |