| NPI | 1043659139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ DI02538700) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D008863) |
| Enumeration Date | 2013-06-21 |
| Last Update Date | 2015-09-09 |