| NPI | 1629715560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA 1859374) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NH 04743) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-05-12 |
| Last Update Date | 2022-10-25 |