| NPI | 1679758304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223E0200X Dentist, Endodontics (Licence: TX 28533) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 21995) |
| 122300000X Dentist (Licence: NH 03639) | |
| 1223E0200X Dentist, Endodontics (Licence: CA 57686) | |
| Enumeration Date | 2007-12-31 |
| Last Update Date | 2019-09-04 |