| NPI | 1952869810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MA DN1859153) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1859153) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-03-08 |
| Last Update Date | 2024-09-20 |