| NPI | 1639518921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN 1856331) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL11569) |
| Enumeration Date | 2013-06-19 |
| Last Update Date | 2023-03-30 |