| NPI | 1508464603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DL14598) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL14598) |
| 1223E0200X Dentist, Endodontics (Licence: MA DL14598) | |
| Enumeration Date | 2020-10-12 |
| Last Update Date | 2021-05-03 |