| NPI | 1114233848 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 055018) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 010332) |
| Enumeration Date | 2010-08-18 |
| Last Update Date | 2013-12-12 |