| NPI | 1720012578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: NY 30972) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: CT 5112) |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2007-07-08 |