| NPI | 1124495312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 060795) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD4614) |
| 1223G0001X Dentist, General Practice (Licence: CA 64738) | |
| Enumeration Date | 2015-08-24 |
| Last Update Date | 2019-10-09 |