| NPI | 1821770439 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 000154-01) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2952000787) |
| Enumeration Date | 2023-08-02 |
| Last Update Date | 2024-10-21 |