| NPI | 1194122705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02610700) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 060373) |
| Enumeration Date | 2014-11-25 |
| Last Update Date | 2024-02-14 |