| NPI | 1609224872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: RI DEN03304) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857190) |
| Enumeration Date | 2016-05-29 |
| Last Update Date | 2022-07-07 |