| NPI | 1245380112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 041879-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS042998) |
| Enumeration Date | 2007-01-11 |
| Last Update Date | 2021-05-11 |