| NPI | 1457569543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 048797) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NJ DI02125300) |
| Enumeration Date | 2007-05-20 |
| Last Update Date | 2007-07-08 |