| NPI | 1588724074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 044777-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS035635) |
| 122300000X Dentist (Licence: OH 30-022151) | |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2007-07-08 |