| NPI | 1457760597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 057395) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 63754) |
| Enumeration Date | 2014-08-02 |
| Last Update Date | 2014-11-17 |