| NPI | 1760482947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA ds036033) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 045378) |
| 122300000X Dentist (Licence: CA 61901) | |
| Enumeration Date | 2005-07-28 |
| Last Update Date | 2013-05-09 |