| NPI | 1548650948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00008057) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO MODS.2766557) |
| 122300000X Dentist (Licence: MA DN19771) | |
| 124Q00000X Dental Hygienist (Licence: MA DH11262) | |
| Enumeration Date | 2015-01-23 |
| Last Update Date | 2018-11-09 |