| NPI | 1225439110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 060142) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856795) |
| 122300000X Dentist (Licence: TX 30345) | |
| Enumeration Date | 2014-09-10 |
| Last Update Date | 2022-05-25 |