| NPI | 1629086582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: NY 219962) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 047041) |
| Enumeration Date | 2006-08-04 |
| Last Update Date | 2016-03-24 |