| NPI | 1356496921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: MD 14635) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 14635) |
| 122300000X Dentist (Licence: NY 052703) | |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2022-07-21 |