| NPI | 1083061899 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 061614) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS040806) |
| Enumeration Date | 2016-05-22 |
| Last Update Date | 2022-02-07 |