| NPI | 1194015743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS038565) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 50 055891) |
| Enumeration Date | 2011-04-17 |
| Last Update Date | 2012-02-02 |