| NPI | 1730621418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 060360) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 101030) |
| 122300000X Dentist (Licence: NY 060360) | |
| Enumeration Date | 2016-11-10 |
| Last Update Date | 2021-12-22 |