| NPI | 1699720623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 040322-01) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 040322-01) |
| 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment | |
| Enumeration Date | 2006-05-25 |
| Last Update Date | 2023-02-14 |