| NPI | 1649320110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 009690) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 041082) |
| Enumeration Date | 2007-01-10 |
| Last Update Date | 2025-01-19 |