| NPI | 1275540742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 000112-01) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NC 0041) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2020-07-31 |