| NPI | 1912621210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 062781) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 062781) |
| Enumeration Date | 2022-09-29 |
| Last Update Date | 2023-04-03 |