| NPI | 1720040975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL 100029) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 037904) |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2015-02-05 |