| NPI | 1225453152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NY 058176) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 058176) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-03-01 |
| Last Update Date | 2019-10-07 |