| NPI | 1790852689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA 15678) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 15678) |
| 1223P0700X Dentist, Prosthodontics (Licence: MA 15650) | |
| Enumeration Date | 2006-11-29 |
| Last Update Date | 2007-07-08 |