| NPI | 1972919686 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 11214) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS040607) |
| 1223G0001X Dentist, General Practice (Licence: NY 058900) | |
| Enumeration Date | 2014-07-02 |
| Last Update Date | 2016-11-21 |