| NPI | 1952773590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 33843) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MA DL12622) |
| Enumeration Date | 2015-10-22 |
| Last Update Date | 2023-03-07 |