| NPI | 1578896676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 054465-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 010096) |
| Enumeration Date | 2009-09-09 |
| Last Update Date | 2015-05-07 |