| NPI | 1558684159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 056558) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 010198) |
| Enumeration Date | 2010-03-10 |
| Last Update Date | 2019-09-11 |