| NPI | 1023114071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY NY0477140) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ NJ22D102047200) |
| Enumeration Date | 2006-09-16 |
| Last Update Date | 2007-07-08 |