| NPI | 1114187762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 057383) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: NY 276236) |
| Enumeration Date | 2008-06-16 |
| Last Update Date | 2020-09-21 |