| NPI | 1396275467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2021044509) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NJ 22DI02713400) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-06-12 |
| Last Update Date | 2022-06-22 |