| NPI | 1619350576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1858185) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1858185) |
| 1223G0001X Dentist, General Practice (Licence: CT 11910) | |
| 1223G0001X Dentist, General Practice (Licence: NY 058692) | |
| Enumeration Date | 2015-07-09 |
| Last Update Date | 2019-02-25 |