| NPI | 1710582127 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02820500) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS042705) |
| Enumeration Date | 2020-12-02 |
| Last Update Date | 2020-12-02 |