| NPI | 1861614562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA ds043083) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 040817) |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2021-05-17 |