| NPI | 1083187538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: NY 061196) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2019-01-08 |
| Last Update Date | 2021-01-19 |