| NPI | 1215289251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 056444) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02500900) |
| Enumeration Date | 2012-10-15 |
| Last Update Date | 2012-10-15 |