| NPI | 1902870587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223E0200X Dentist, Endodontics (Licence: CA 59088) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 20019) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: MA 20019) | |
| Enumeration Date | 2006-02-13 |
| Last Update Date | 2014-01-13 |