| NPI | 1497380323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA 1859704) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 9951) |
| 122300000X Dentist (Licence: CA 107122) | |
| 122300000X Dentist (Licence: NH 04814) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-03-11 |
| Last Update Date | 2024-03-12 |