| NPI | 1043652886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02571500) |
| Additional Taxonomies | 1223P0700X Dentist Prosthodontics (Licence: NY 056707) |
| Enumeration Date | 2013-07-22 |
| Last Update Date | 2016-03-16 |