| NPI | 1902203532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 11712) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856779) |
| Enumeration Date | 2014-11-25 |
| Last Update Date | 2020-02-20 |