| NPI | 1104131275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 058173) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 7737284-9921) |
| Enumeration Date | 2010-08-13 |
| Last Update Date | 2019-05-06 |