| NPI | 1558649947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 9900) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 055454) |
| Enumeration Date | 2011-08-02 |
| Last Update Date | 2022-02-24 |