| NPI | 1124150701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: PA DS036579) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NJ 22DI02290300) |
| Enumeration Date | 2007-03-10 |
| Last Update Date | 2013-02-12 |