| NPI | 1063974459 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02997300) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 061329) |
| Enumeration Date | 2019-04-03 |
| Last Update Date | 2025-05-05 |