| NPI | 1962796201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: NY 055460) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NY 055460) |
| Enumeration Date | 2011-06-03 |
| Last Update Date | 2014-10-02 |