| NPI | 1558047787 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NJ 22DI03066500) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS044936) |
| Enumeration Date | 2023-06-22 |
| Last Update Date | 2025-01-18 |