| NPI | 1871595983 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: AZ 7256) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 051498) |
| Enumeration Date | 2005-06-01 |
| Last Update Date | 2013-07-09 |