| NPI | 1912265141 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL 22567) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 056715) |
| Enumeration Date | 2012-04-25 |
| Last Update Date | 2018-03-20 |