| NPI | 1609992064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: PA DS037411) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 052199) |
| 122300000X Dentist (Licence: NJ 22DI02295500) | |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2013-09-27 |