| NPI | 1124018130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 48481) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 47985) |
| Enumeration Date | 2005-10-21 |
| Last Update Date | 2007-07-09 |