| NPI | 1427724624 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS044036) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02858000) |
| Enumeration Date | 2021-08-18 |
| Last Update Date | 2023-05-10 |