| NPI | 1619002912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 054775) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 50 054775) |
| 1223G0001X Dentist, General Practice (Licence: MA 21604) | |
| Enumeration Date | 2007-02-23 |
| Last Update Date | 2017-06-02 |