| NPI | 1790934305 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 6992) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 052249) |
| Enumeration Date | 2008-09-18 |
| Last Update Date | 2011-06-27 |