| NPI | 1710208004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 10572) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 10274) |
| 1223G0001X Dentist, General Practice (Licence: MA DN1856419) | |
| Enumeration Date | 2010-06-21 |
| Last Update Date | 2022-03-01 |