| NPI | 1982653804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: VA 0401410614) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: MA 15833) |
| Enumeration Date | 2006-05-08 |
| Last Update Date | 2007-07-08 |