| NPI | 1215079363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 10632) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 052587) |
| Enumeration Date | 2007-02-13 |
| Last Update Date | 2017-12-28 |