| NPI | 1659462026 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 040136-1) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 040136) |
| Enumeration Date | 2006-09-28 |
| Last Update Date | 2011-05-18 |