| NPI | 1780675298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS029756L) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA DDS-09035) |
| 122300000X Dentist (Licence: NJ 22D102312900) | |
| Enumeration Date | 2005-11-03 |
| Last Update Date | 2013-08-07 |