| NPI | 1962509588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist, Prosthodontics (Licence: NY 053230) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901019029) |
| 1223P0700X Dentist, Prosthodontics (Licence: NJ 22DI02334300) | |
| Enumeration Date | 2006-09-17 |
| Last Update Date | 2010-05-23 |