| NPI | 1841674157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 059571) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 011442) |
| Enumeration Date | 2015-07-16 |
| Last Update Date | 2019-02-07 |