| NPI | 1457734436 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 058578) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 058578) |
| Enumeration Date | 2015-07-08 |
| Last Update Date | 2021-11-30 |