| NPI | 1629090030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL DN23896) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 040888) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2020-06-04 |