| NPI | 1275092678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 061039) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NY 061039) |
| Enumeration Date | 2019-03-15 |
| Last Update Date | 2023-06-01 |