| NPI | 1063526226 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 054818) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OH 20799) |
| Enumeration Date | 2006-08-17 |
| Last Update Date | 2014-01-02 |