| NPI | 1063874287 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 059307) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 670517618) |
| Enumeration Date | 2016-03-26 |
| Last Update Date | 2022-10-10 |