| NPI | 1659749612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NY 061725) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.030227) |
| Enumeration Date | 2015-09-08 |
| Last Update Date | 2021-07-15 |