| NPI | 1710285978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DL14210) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401413092) |
| Enumeration Date | 2011-03-11 |
| Last Update Date | 2020-06-22 |