| NPI | 1649762162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1858242) |
| Additional Taxonomies | 122300000X Dentist (Licence: RI DEN03438) |
| Enumeration Date | 2018-05-31 |
| Last Update Date | 2019-05-08 |