| NPI | 1568742815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CT 011288) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 055695) |
| Enumeration Date | 2011-08-18 |
| Last Update Date | 2018-01-17 |