| NPI | 1023456381 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 26115) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 26115) |
| Enumeration Date | 2013-06-10 |
| Last Update Date | 2013-06-10 |