| NPI | 1619930864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist Prosthodontics (Licence: NY 047563) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 047563) |
| 1223G0001X Dentist General Practice (Licence: NY 047563) | |
| Enumeration Date | 2006-04-10 |
| Last Update Date | 2020-07-13 |