| NPI | 1760612857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 010347) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1855224) |
| Enumeration Date | 2009-07-23 |
| Last Update Date | 2013-08-27 |