| NPI | 1194899575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 35200) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NJ 22DI01865800) |
| Enumeration Date | 2006-11-20 |
| Last Update Date | 2023-04-25 |