| NPI | 1720118375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: NY 000248) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 32715) |
| 1223G0001X Dentist, General Practice (Licence: CO 7717) | |
| Enumeration Date | 2007-03-06 |
| Last Update Date | 2014-05-15 |