| NPI | 1821250820 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA 22226) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 25779) |
| Enumeration Date | 2008-06-30 |
| Last Update Date | 2017-07-07 |