| NPI | 1164976213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02648000) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN22172) |
| 122300000X Dentist (Licence: CT 11673) | |
| Enumeration Date | 2016-08-06 |
| Last Update Date | 2016-12-11 |