| NPI | 1124436472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: IL 19030503) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30408) |
| Enumeration Date | 2014-07-31 |
| Last Update Date | 2024-04-24 |