| NPI | 1609404953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02933700) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS043007) |
| Enumeration Date | 2020-03-31 |
| Last Update Date | 2023-03-22 |