| NPI | 1659475986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 047191) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 4621) |
| Enumeration Date | 2006-09-08 |
| Last Update Date | 2011-04-14 |