| NPI | 1801025945 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 0025165) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1855212) |
| Enumeration Date | 2009-07-10 |
| Last Update Date | 2014-09-16 |