| NPI | 1508153099 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02484400) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: CT 010721) | |
| Enumeration Date | 2011-07-05 |
| Last Update Date | 2012-07-11 |