| NPI | 1790746311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: AZ D6260) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019-026230) |
| 1223P0300X Dentist, Periodontics (Licence: NY 053711-1) | |
| 1223P0300X Dentist, Periodontics (Licence: TX 28440) | |
| Enumeration Date | 2006-03-31 |
| Last Update Date | 2016-04-05 |