| NPI | 1053657577 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 31480) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22D102524800) |
| 122300000X Dentist (Licence: NY 056888) | |
| Enumeration Date | 2013-01-02 |
| Last Update Date | 2016-11-15 |