| NPI | 1962105098 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN10001596) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 112498) |
| Enumeration Date | 2023-03-27 |
| Last Update Date | 2026-07-28 |