| NPI | 1669792412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02552000) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 055655) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NJ 22DI02552000) | |
| Enumeration Date | 2010-06-03 |
| Last Update Date | 2017-10-31 |