| NPI | 1912225491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 50 054916) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02435100) |
| Enumeration Date | 2010-05-09 |
| Last Update Date | 2014-07-09 |