| NPI | 1952698490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22DI02479600) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1855749) |
| Enumeration Date | 2011-07-05 |
| Last Update Date | 2014-08-01 |