| NPI | 1689685836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA 12396) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 61182) |
| Enumeration Date | 2006-08-11 |
| Last Update Date | 2013-01-15 |