| NPI | 1902351836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 103835) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857403) |
| Enumeration Date | 2016-08-21 |
| Last Update Date | 2019-07-17 |