| NPI | 1033231394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: LA 7151) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 052263-1) |
| Enumeration Date | 2007-04-05 |
| Last Update Date | 2021-03-05 |