| NPI | 1902011497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 053865) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02332400) |
| Enumeration Date | 2007-05-10 |
| Last Update Date | 2016-04-21 |