| NPI | 1861789638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 056590-1) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 056590-1) |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2016-03-25 |