| NPI | 1164755989 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0700X Dentist, Prosthodontics (Licence: NY 060273) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IA 30345) |
| Enumeration Date | 2009-09-11 |
| Last Update Date | 2020-10-20 |