| NPI | 1215628508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 064109) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN10000194) |
| Enumeration Date | 2023-05-17 |
| Last Update Date | 2026-02-16 |