| NPI | 1851759401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 059365) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041299) |
| 122300000X Dentist (Licence: NJ 22DI02659500) | |
| 122300000X Dentist (Licence: CT 11762) | |
| Enumeration Date | 2016-02-10 |
| Last Update Date | 2017-10-02 |