| NPI | 1558707406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 056854) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 62920) |
| Enumeration Date | 2013-05-20 |
| Last Update Date | 2020-03-19 |