| NPI | 1376079640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS041929) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NY 060095) |
| Enumeration Date | 2017-05-05 |
| Last Update Date | 2023-04-15 |