| NPI | 1629403779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DL12042) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 63310) |
| Enumeration Date | 2013-09-09 |
| Last Update Date | 2016-04-29 |