| NPI | 1720408990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NY 058160) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 3902000000X) |
| Enumeration Date | 2014-04-25 |
| Last Update Date | 2021-02-12 |