| NPI | 1104003276 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 055999) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02302000) |
| Enumeration Date | 2008-01-30 |
| Last Update Date | 2016-01-15 |