| NPI | 1801174198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1855826) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 010677) |
| Enumeration Date | 2011-08-03 |
| Last Update Date | 2013-08-12 |