| NPI | 1215189493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401412299) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 053043) |
| Enumeration Date | 2008-10-19 |
| Last Update Date | 2008-10-19 |