| NPI | 1902324627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist, Prosthodontics (Licence: MA DF11658) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 151165) |
| Enumeration Date | 2017-09-01 |
| Last Update Date | 2021-02-04 |