| NPI | 1740598739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 059457-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ DI024821) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: NJ 22DR02327) | |
| Enumeration Date | 2010-09-23 |
| Last Update Date | 2023-03-07 |