| NPI | 1669724621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 11086) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22D102520300) |
| Enumeration Date | 2012-10-15 |
| Last Update Date | 2015-01-20 |