| NPI | 1740389535 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: SC 8860) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 037561) |
| 1223G0001X Dentist General Practice (Licence: NC 10635) | |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2021-01-07 |