| NPI | 1790036010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 056271) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 056271) |
| Enumeration Date | 2012-09-26 |
| Last Update Date | 2015-09-18 |