| NPI | 1609131937 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 058308) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 10801) |
| Enumeration Date | 2012-07-12 |
| Last Update Date | 2026-03-17 |