| NPI | 1780814954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1855225) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040531) |
| Enumeration Date | 2009-07-21 |
| Last Update Date | 2016-01-11 |