| NPI | 1760562235 |
|---|---|
| Former Name | JEREMY RUSSELL LUSTIG |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: TX 20612) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2024-02-28 |