| NPI | 1457635112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NJ 22DI02482600) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 010719) |
| Enumeration Date | 2011-09-29 |
| Last Update Date | 2016-03-28 |