| NPI | 1639473929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NY 055514) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS038020) |
| Enumeration Date | 2010-12-31 |
| Last Update Date | 2016-03-25 |