| NPI | 1053386805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AZ D6021) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NY 023502) |
| Enumeration Date | 2006-02-22 |
| Last Update Date | 2007-07-08 |