| NPI | 1114420627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: FL 28929) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 060602) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-10 |
| Last Update Date | 2024-07-08 |