| NPI | 1174195192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 063604) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 12391) |
| Enumeration Date | 2021-07-12 |
| Last Update Date | 2025-01-17 |