| NPI | 1083147813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 059905) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 315832654) |
| Enumeration Date | 2017-04-08 |
| Last Update Date | 2018-07-31 |