| NPI | 1649651670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1857506) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 11626) |
| 122300000X Dentist (Licence: NH 04163) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-06-16 |
| Last Update Date | 2021-10-18 |