| NPI | 1649694696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 057986) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02603700) |
| Enumeration Date | 2014-02-11 |
| Last Update Date | 2022-07-21 |