| NPI | 1457762585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 000050-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN19832) |
| 122300000X Dentist (Licence: CT 11122) | |
| Enumeration Date | 2014-05-12 |
| Last Update Date | 2021-04-30 |