| NPI | 1659855914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401416132) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ME DEN4663) |
| Enumeration Date | 2018-09-21 |
| Last Update Date | 2021-06-01 |