| NPI | 1871650945 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA 19610) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MA 19610) |
| Enumeration Date | 2007-01-01 |
| Last Update Date | 2019-01-17 |