| NPI | 1073135711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 061775) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE61102195) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-05-16 |
| Last Update Date | 2021-10-01 |