| NPI | 1316169311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 040724-1) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MA 16853) |
| Enumeration Date | 2007-05-02 |
| Last Update Date | 2007-07-08 |