| NPI | 1336424100 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 056187) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NJ DI02482000) |
| Enumeration Date | 2011-10-12 |
| Last Update Date | 2015-01-28 |