| NPI | 1700144318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401414689) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15376) |
| 122300000X Dentist (Licence: NY 056808) | |
| Enumeration Date | 2012-05-02 |
| Last Update Date | 2021-06-23 |