| NPI | 1770620445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 8082) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 19654) |
| Enumeration Date | 2007-01-31 |
| Last Update Date | 2014-01-27 |