| NPI | 1497323497 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN10000714) | 
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS043332) | 
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-06-15 | 
| Last Update Date | 2025-07-14 |