| NPI | 1912102849 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NH 03932) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VT 016-0002247) |
| Enumeration Date | 2007-06-20 |
| Last Update Date | 2015-03-09 |