| NPI | 1235635723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ DI02735300) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 060719) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-03 |
| Last Update Date | 2023-09-20 |