| NPI | 1245728104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 062608) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.025666) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-26 |
| Last Update Date | 2024-10-15 |