| NPI | 1629224555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: ME 2962) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NJ 22DI01347900) |
| Enumeration Date | 2008-08-12 |
| Last Update Date | 2013-09-03 |