| NPI | 1679853063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413547) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1855839) |
| Enumeration Date | 2011-08-17 |
| Last Update Date | 2019-03-19 |