| NPI | 1558352575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN17856) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 051507) |
| Enumeration Date | 2005-10-31 |
| Last Update Date | 2012-11-08 |