| NPI | 1598029357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 056102) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 010765) |
| Enumeration Date | 2012-06-26 |
| Last Update Date | 2013-03-04 |