| NPI | 1386916401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS038794) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02551400) |
| Enumeration Date | 2012-02-06 |
| Last Update Date | 2015-08-19 |