| NPI | 1164742904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS040183) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: NJ 28RI03075300) |
| 122300000X Dentist (Licence: NJ 22DI02496300) | |
| Enumeration Date | 2010-06-03 |
| Last Update Date | 2015-07-10 |