| NPI | 1952715591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN1856872) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901021277) |
| Enumeration Date | 2014-06-11 |
| Last Update Date | 2019-04-23 |