| NPI | 1114120763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401411298) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0401411298) |
| 122300000X Dentist (Licence: NY 053571-1) | |
| Enumeration Date | 2007-06-08 |
| Last Update Date | 2023-01-12 |