| NPI | 1962619551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 048787-1) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: NY 048787) |
| Enumeration Date | 2007-05-16 |
| Last Update Date | 2022-04-25 |