| NPI | 1083992101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 055671) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 010593) |
| Enumeration Date | 2011-07-22 |
| Last Update Date | 2011-08-10 |