| NPI | 1750580973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 043543) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 8249) |
| Enumeration Date | 2007-07-17 |
| Last Update Date | 2016-03-10 |