| NPI | 1619224565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 16579) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VT 016.0134406) |
| Enumeration Date | 2012-08-09 |
| Last Update Date | 2025-12-10 |