| NPI | 1477122752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1859694) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 2021023350) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA 309200000X) | |
| Enumeration Date | 2021-06-22 |
| Last Update Date | 2023-08-25 |