| NPI | 1861510042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CT 006665) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 038826-1) |
| Enumeration Date | 2007-03-27 |
| Last Update Date | 2012-11-26 |