| NPI | 1972739274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ME DEN4256) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2009013195) |
| Enumeration Date | 2009-06-02 |
| Last Update Date | 2013-05-17 |