| NPI | 1467139758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2025023197) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI03096900) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-06-29 |
| Last Update Date | 2025-06-17 |