| NPI | 1003512690 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 14241) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 064051) |
| Enumeration Date | 2023-02-06 |
| Last Update Date | 2024-12-01 |