| NPI | 1578609087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02588100) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 14338) |
| 122300000X Dentist (Licence: PA DS041716) | |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2021-05-13 |