| NPI | 1285704056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 15215) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 053576) |
| 122300000X Dentist (Licence: VA 0401413923) | |
| Enumeration Date | 2006-11-09 |
| Last Update Date | 2015-06-04 |