| NPI | 1336203827 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MA DN1856441) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 033152-1) |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2023-09-08 |