| NPI | 1669855607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 32904) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL12619) |
| Enumeration Date | 2015-07-08 |
| Last Update Date | 2020-02-18 |