| NPI | 1003093352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 053882) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 05-053882) |
| 122300000X Dentist (Licence: CA 59115) | |
| Enumeration Date | 2008-01-29 |
| Last Update Date | 2020-09-29 |