| NPI | 1376534594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 0346651) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401008127) |
| Enumeration Date | 2005-11-04 |
| Last Update Date | 2007-07-08 |