| NPI | 1710134812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA 22306) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: MA DN22306) |
| Enumeration Date | 2008-08-20 |
| Last Update Date | 2016-05-30 |