| NPI | 1750637732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901021181) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02511800) |
| 122300000X Dentist (Licence: NY 056316) | |
| Enumeration Date | 2012-07-27 |
| Last Update Date | 2014-08-07 |