| NPI | 1700234739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401415090) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857355) |
| Enumeration Date | 2016-05-31 |
| Last Update Date | 2017-01-31 |