| NPI | 1386055929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 058276) |
| Additional Taxonomies | 282N00000X General Acute Care Hospital |
| 261QD0000X Clinic/Center, Dental (Licence: NY 058276) | |
| Enumeration Date | 2014-05-16 |
| Last Update Date | 2017-03-20 |