| NPI | 1417208562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 32787) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02518300) |
| 122300000X Dentist (Licence: PA DS039309) | |
| Enumeration Date | 2012-09-28 |
| Last Update Date | 2018-05-03 |