| NPI | 1336289594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 0444231) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: NY 0500881) |
| Enumeration Date | 2007-02-07 |
| Last Update Date | 2007-07-08 |