| NPI | 1417077215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 007689) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 0405841) |
| Enumeration Date | 2007-03-29 |
| Last Update Date | 2007-07-08 |