| NPI | 1538416912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS039105) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NJ 22DI02510100) |
| Enumeration Date | 2012-08-06 |
| Last Update Date | 2021-02-25 |