| NPI | 1508533647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA 10000735) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401417474) |
| 122300000X Dentist (Licence: MD 17557) | |
| Enumeration Date | 2021-08-26 |
| Last Update Date | 2025-08-26 |