| NPI | 1740650340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 058758) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 0587581) |
| Enumeration Date | 2015-09-25 |
| Last Update Date | 2022-08-04 |