| NPI | 1265828297 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02578500) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 058564-1) |
| Enumeration Date | 2015-04-07 |
| Last Update Date | 2016-11-13 |