| NPI | 1386774552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 029092-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 029092-1) |
| Enumeration Date | 2007-03-06 |
| Last Update Date | 2011-06-16 |