| NPI | 1255627576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 057238-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 011185) |
| 1223G0001X Dentist, General Practice (Licence: NJ 22DI02471200) | |
| Enumeration Date | 2011-06-24 |
| Last Update Date | 2021-02-17 |