| NPI | 1114188794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 31507) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02100700) |
| Enumeration Date | 2008-06-17 |
| Last Update Date | 2016-11-08 |