| NPI | 1861686875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC 9268) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 052778) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: NC 2017-02466) | |
| 208D00000X General Practice (Licence: NY 269639) | |
| Enumeration Date | 2007-09-02 |
| Last Update Date | 2017-11-22 |