| NPI | 1275016073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS042943) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02724300) |
| Enumeration Date | 2018-09-08 |
| Last Update Date | 2021-05-06 |