| NPI | 1871967497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1857431) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 2.011664) |
| Enumeration Date | 2015-11-19 |
| Last Update Date | 2016-10-24 |