| NPI | 1205042736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY NY052523-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 5620-015) |
| Enumeration Date | 2007-05-14 |
| Last Update Date | 2007-07-08 |