| NPI | 1609920628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: UT 10450041-9922) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: NY 044620-1) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2021-03-04 |