| NPI | 1639415987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MA DN1856141) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 28603) |
| Enumeration Date | 2012-12-13 |
| Last Update Date | 2015-02-17 |