| NPI | 1952710709 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 059670) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401414485) |
| Enumeration Date | 2014-08-06 |
| Last Update Date | 2018-06-19 |