| NPI | 1558537589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 059586) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9110924) |
| Enumeration Date | 2008-04-30 |
| Last Update Date | 2018-10-03 |