| NPI | 1205239936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 057641) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NJ 22DI02581500) |
| Enumeration Date | 2014-10-08 |
| Last Update Date | 2017-03-13 |