| NPI | 1609200013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DL12002) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: VA 0401417461) |
| Enumeration Date | 2013-08-21 |
| Last Update Date | 2021-11-10 |