| NPI | 1134560782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NJ 22DI02627900) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856338) |
| Enumeration Date | 2013-07-11 |
| Last Update Date | 2016-06-02 |