| NPI | 1790920049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 054830-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02390000) |
| Enumeration Date | 2008-12-15 |
| Last Update Date | 2023-11-05 |