| NPI | 1790199438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1856608) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MA DN1856608) |
| Enumeration Date | 2014-06-19 |
| Last Update Date | 2014-06-19 |