| NPI | 1790378438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 062510-01) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 062510) |
| Enumeration Date | 2021-02-13 |
| Last Update Date | 2022-09-02 |