| NPI | 1679742456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413034) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02322100) |
| Enumeration Date | 2008-02-26 |
| Last Update Date | 2020-08-25 |