| NPI | 1457744633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 058503) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY Taxonomy Number: 390) |
| Enumeration Date | 2015-03-11 |
| Last Update Date | 2018-02-26 |