| NPI | 1770787954 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: PA DS038977) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 21845) |
| 1223G0001X Dentist, General Practice (Licence: PA DS038977) | |
| 1223G0001X Dentist, General Practice (Licence: NJ 22DI02352900) | |
| Enumeration Date | 2007-06-12 |
| Last Update Date | 2020-12-10 |