| NPI | 1568848596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QA1903X Clinic/Center, Ambulatory Surgical |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 059011) |
| Enumeration Date | 2015-07-31 |
| Last Update Date | 2018-01-16 |