| NPI | 1760741201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 049947) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 50 049947) |
| Enumeration Date | 2012-05-03 |
| Last Update Date | 2023-07-16 |