| NPI | 1063613602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: NJ 22D100923600) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: PA DS018710L) |
| Enumeration Date | 2007-05-30 |
| Last Update Date | 2019-03-18 |