| NPI | 1700197696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1855472) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 28715) |
| Enumeration Date | 2010-06-25 |
| Last Update Date | 2024-03-26 |