| NPI | 1679102636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02786600) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS043800) |
| Enumeration Date | 2020-04-02 |
| Last Update Date | 2022-07-29 |