| NPI | 1568685352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CT 009577) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty (Licence: CT 9577) |
| 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment (Licence: CT 9577) | |
| 1223G0001X Dentist, General Practice (Licence: CT 9577) | |
| Enumeration Date | 2007-04-10 |
| Last Update Date | 2026-07-01 |