| NPI | 1366883548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: FL DN23158) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY DN014539) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: NY 058492-1) | |
| Enumeration Date | 2013-07-16 |
| Last Update Date | 2023-06-19 |