| NPI | 1316501604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS042650) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02803700) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-23 |
| Last Update Date | 2021-02-18 |