| NPI | 1417162116 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 053288) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: NY 271496) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CT 12168) | |
| Enumeration Date | 2007-05-14 |
| Last Update Date | 2024-03-01 |