| NPI | 1861654543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 055657) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS037983) |
| 122300000X Dentist (Licence: PA Student) | |
| Enumeration Date | 2008-06-25 |
| Last Update Date | 2022-06-02 |