| NPI | 1912126525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 038874) |
| Additional Taxonomies | 1223D0001X Dentist, Dental Public Health (Licence: NY 038874) |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2007-07-08 |