| NPI | 1649654310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MA DN1856943) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856943) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA DN1856943) | |
| Enumeration Date | 2015-07-13 |
| Last Update Date | 2017-07-13 |