| NPI | 1922363696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NY 058100) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039064) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 058100) | |
| Enumeration Date | 2012-07-09 |
| Last Update Date | 2015-08-24 |