| NPI | 1619173655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 054827-1) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 6111-015) |
| Enumeration Date | 2007-06-26 |
| Last Update Date | 2010-06-17 |