| NPI | 1477108074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1858869) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 14437) |
| 122300000X Dentist (Licence: TX 35557) | |
| 122300000X Dentist (Licence: CA DDS104887) | |
| Enumeration Date | 2019-08-09 |
| Last Update Date | 2026-01-08 |