| NPI | 1861519951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 059069-1) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 11856) |
| Enumeration Date | 2007-03-23 |
| Last Update Date | 2018-06-02 |