| NPI | 1578766036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401411454) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 054846) |
| Enumeration Date | 2007-06-11 |
| Last Update Date | 2015-12-09 |