| NPI | 1235302761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 051867) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL dn17044) |
| Enumeration Date | 2008-04-04 |
| Last Update Date | 2012-06-08 |