| NPI | 1720329162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS039093) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02523800) |
| Enumeration Date | 2013-03-11 |
| Last Update Date | 2013-03-11 |