| NPI | 1861975989 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1858123) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN23745) |
| Enumeration Date | 2018-09-14 |
| Last Update Date | 2018-10-01 |