| NPI | 1700184744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 043632-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA DDS-10078) |
| Enumeration Date | 2011-02-28 |
| Last Update Date | 2024-01-19 |