| NPI | 1245350446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 036735) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 036735) |
| 1223P0700X Dentist, Prosthodontics (Licence: NY 036735) | |
| Enumeration Date | 2007-03-30 |
| Last Update Date | 2025-06-02 |