| NPI | 1972395879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MA DN10001453) |
| Additional Taxonomies | 1223D0001X Dentist, Dental Public Health (Licence: SC 11074) |
| 122300000X Dentist (Licence: SC 11074) | |
| 1223G0001X Dentist, General Practice (Licence: SC 11074) | |
| Enumeration Date | 2025-05-19 |
| Last Update Date | 2026-10-05 |