| NPI | 1003809302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CT 11372) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 048502) |
| Enumeration Date | 2005-08-23 |
| Last Update Date | 2018-05-30 |