| NPI | 1457577629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 482791) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 0482791) |
| Enumeration Date | 2007-04-17 |
| Last Update Date | 2019-12-31 |