| NPI | 1629294111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 035269) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: NY 035269) |
| 332BC3200X Durable Medical Equipment & Medical Supplies Customized Equipment | |
| Enumeration Date | 2007-04-17 |
| Last Update Date | 2020-04-07 |