| NPI | 1497096689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 026257) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 11755) |
| Enumeration Date | 2013-03-13 |
| Last Update Date | 2015-07-14 |