| NPI | 1457611063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 058314) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 11046) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-05-17 |
| Last Update Date | 2025-05-15 |