| NPI | 1083117337 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 062289) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: CO DEN.00203981) | |
| 1223G0001X Dentist, General Practice (Licence: MI 2901600137) | |
| Enumeration Date | 2018-03-13 |
| Last Update Date | 2023-05-19 |