| NPI | 1568454460 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 32813) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NJ 22DI01143300) |
| Enumeration Date | 2005-08-17 |
| Last Update Date | 2007-07-08 |