| NPI | 1457630923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 055718) |
| Additional Taxonomies | 1223E0200X Dentist Endodontics (Licence: NY 055718) |
| Enumeration Date | 2011-08-15 |
| Last Update Date | 2013-04-30 |