| NPI | 1679041008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 104290) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NJ 22DI02729500) |
| Enumeration Date | 2018-11-03 |
| Last Update Date | 2019-10-01 |