| NPI | 1700218120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 056843) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02553700) |
| Enumeration Date | 2013-08-08 |
| Last Update Date | 2021-09-30 |