| NPI | 1851415327 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 35149) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 035149) |
| Enumeration Date | 2007-03-19 |
| Last Update Date | 2012-04-05 |