| NPI | 1790343655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02754600) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 059388-1) |
| Enumeration Date | 2019-06-04 |
| Last Update Date | 2021-07-09 |