| NPI | 1770618506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1855757) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.022311) |
| Enumeration Date | 2007-02-22 |
| Last Update Date | 2012-03-02 |