| NPI | 1104086669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 057127) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.027495) |
| Enumeration Date | 2008-06-09 |
| Last Update Date | 2021-08-23 |