| NPI | 1134189509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 122300000X Dentist (Licence: NY NY039882) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401006644) |
| Enumeration Date | 2006-03-28 |
| Last Update Date | 2007-07-08 |