| NPI | 1518410836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MA mcs000675d) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: TX 32114) |
| Enumeration Date | 2016-08-03 |
| Last Update Date | 2021-05-20 |