| NPI | 1164817433 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 058713-1) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 058713-1) |
| 1223G0001X Dentist, General Practice (Licence: GA DN015348) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-04-02 |
| Last Update Date | 2024-11-19 |