| NPI | 1649610536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA DDS63130) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02540600) |
| Enumeration Date | 2013-06-25 |
| Last Update Date | 2016-09-16 |