| NPI | 1174063002 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 060049) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 060049) |
| Enumeration Date | 2017-02-25 |
| Last Update Date | 2020-06-23 |