Individual
MINSUB BAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
546 MAIN ST, ATHOL, MA 01331-1821
(978) 830-4610
Mailing address
4042 GUINEA RD, FAIRFAX, VA 22032-1413
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DN10000417
MA
Other
Enumeration date
06/13/2024
Last updated
11/02/2024
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