| NPI | 1972767127 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 054137-1) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02382000) |
| Enumeration Date | 2008-07-17 |
| Last Update Date | 2012-04-24 |