| NPI | 1962469908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN21319) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 049163-1) |
| 122300000X Dentist (Licence: MA 21319) | |
| Enumeration Date | 2006-04-26 |
| Last Update Date | 2012-02-14 |