| NPI | 1417335142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CT 11743) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 057084) |
| Enumeration Date | 2015-05-14 |
| Last Update Date | 2024-09-08 |