| NPI | 1265714067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 64401) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02474000) |
| Enumeration Date | 2011-09-16 |
| Last Update Date | 2023-09-15 |