| NPI | 1609284280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1857846) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD4152) |
| Enumeration Date | 2014-07-28 |
| Last Update Date | 2018-12-06 |