| NPI | 1568569473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MA 19726) |
| Additional Taxonomies | 261QD0000X Clinic/Center Dental (Licence: MA 19726) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2008-03-03 |