| NPI | 1639464662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MA DN1855732) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1855732) |
| Enumeration Date | 2011-06-17 |
| Last Update Date | 2024-02-13 |