| NPI | 1104942606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 047291) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CT 11091) |
| Enumeration Date | 2007-03-22 |
| Last Update Date | 2019-06-05 |