| NPI | 1588082002 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NH 04147) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 0000000000) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-04-01 |
| Last Update Date | 2021-05-21 |