| NPI | 1902989858 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 050404) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02451000) |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2011-02-01 |