| NPI | 1831369511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1855255) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.022705) |
| Enumeration Date | 2008-03-10 |
| Last Update Date | 2009-09-30 |