| NPI | 1669518676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 051203) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401411803) |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2011-06-20 |