| NPI | 1114374576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NY 058538-1) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NJ 22DI025605500) |
| Enumeration Date | 2016-05-16 |
| Last Update Date | 2016-08-09 |