| NPI | 1679866156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA 1855666) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: RI 03121) |
| Enumeration Date | 2011-05-17 |
| Last Update Date | 2011-06-17 |