| NPI | 1083094528 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ME DEN4426) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02584900) |
| Enumeration Date | 2015-05-30 |
| Last Update Date | 2015-07-20 |