| NPI | 1962983742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DL13804) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA DL13804) |
| Enumeration Date | 2018-08-28 |
| Last Update Date | 2019-05-15 |