| NPI | 1790817054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS026789L) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ DI016279) |
| Enumeration Date | 2007-03-12 |
| Last Update Date | 2007-07-08 |