| NPI | 1801543293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 063736) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 12389) |
| Enumeration Date | 2022-03-04 |
| Last Update Date | 2025-06-07 |