| NPI | 1710290903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 0025734) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1855884) |
| Enumeration Date | 2010-07-16 |
| Last Update Date | 2012-01-13 |