| NPI | 1518159706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: PA DS043548) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02929700) |
| 1223P0300X Dentist Periodontics (Licence: PA SDO43548) | |
| 1223P0300X Dentist Periodontics (Licence: MI 2901019690) | |
| 1223P0300X Dentist Periodontics (Licence: NJ 22DI02929700) | |
| Enumeration Date | 2007-08-13 |
| Last Update Date | 2024-04-01 |