| NPI | 1972009801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1858048) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MA DN1858048) |
| Enumeration Date | 2018-03-31 |
| Last Update Date | 2022-07-26 |