| NPI | 1679868822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CT 4383) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: NY 044912-1) |
| 1223P0300X Dentist, Periodontics (Licence: MA dn11169) | |
| Enumeration Date | 2011-06-16 |
| Last Update Date | 2012-03-29 |