| NPI | 1104231661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 50 058211) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02612700) |
| Enumeration Date | 2014-06-24 |
| Last Update Date | 2015-11-02 |