| NPI | 1962805101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA 14897) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 11301) |
| 1223G0001X Dentist General Practice (Licence: MD 15864) | |
| Enumeration Date | 2014-10-02 |
| Last Update Date | 2021-11-18 |