| NPI | 1114308855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 062474) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.026201) |
| 122300000X Dentist (Licence: PA DS042004) | |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: IL 018001949) | |
| Enumeration Date | 2015-06-17 |
| Last Update Date | 2022-08-01 |