| NPI | 1700973567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA ds037319) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 052102) |
| 1223G0001X Dentist, General Practice (Licence: NJ DI02310800) | |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2016-02-22 |