| NPI | 1992109524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 33403) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856791) |
| 122300000X Dentist (Licence: CT 11302) | |
| 1223G0001X Dentist, General Practice (Licence: CT 11302) | |
| Enumeration Date | 2014-10-10 |
| Last Update Date | 2020-07-23 |