| NPI | 1730265729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA 22089) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401410517) |
| Enumeration Date | 2006-10-31 |
| Last Update Date | 2010-10-04 |