| NPI | 1174547152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: NY 2144721) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 0482431) |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2016-03-28 |