| NPI | 1235394172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL dn18905) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 053912) |
| Enumeration Date | 2008-07-21 |
| Last Update Date | 2012-10-07 |