| NPI | 1891912564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY NY042669-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 0426691) |
| Enumeration Date | 2007-04-20 |
| Last Update Date | 2009-04-22 |