| NPI | 1457617029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN20214) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 50057019) |
| Enumeration Date | 2012-04-07 |
| Last Update Date | 2014-03-31 |