| NPI | 1043524200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 055027) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 50055027) |
| Enumeration Date | 2010-07-29 |
| Last Update Date | 2021-12-13 |