| NPI | 1174939557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 50 057503) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CT 11202) |
| Enumeration Date | 2014-07-07 |
| Last Update Date | 2015-10-19 |