| NPI | 1396926150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL 18041) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 053453-1) |
| Enumeration Date | 2007-11-21 |
| Last Update Date | 2019-06-11 |