| NPI | 1003809773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist Prosthodontics (Licence: CT 009652) |
| Additional Taxonomies | 1223P0700X Dentist Prosthodontics (Licence: NY 048520-1) |
| Enumeration Date | 2005-08-26 |
| Last Update Date | 2013-08-21 |