| NPI | 1790940518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MD 14492) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 053937) |
| Enumeration Date | 2008-07-21 |
| Last Update Date | 2022-05-25 |