| NPI | 1780768945 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 045285-1) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: NY 213109) |
| Enumeration Date | 2006-10-24 |
| Last Update Date | 2007-07-08 |