| NPI | 1801236856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1857378) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 11740) |
| Enumeration Date | 2013-07-04 |
| Last Update Date | 2019-04-01 |