| NPI | 1114940020 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 106997) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 033879) |
| 1223G0001X Dentist, General Practice (Licence: NY 033879-1) | |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2022-11-30 |