| NPI | 1730731563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 062511) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL 24365) |
| Enumeration Date | 2019-07-11 |
| Last Update Date | 2023-08-02 |