| NPI | 1780691618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 61013) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 40470) |
| Enumeration Date | 2006-08-02 |
| Last Update Date | 2021-10-04 |