| NPI | 1487046587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 058133) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: 39020000X) |
| 1223G0001X Dentist, General Practice (Licence: CT 11380) | |
| Enumeration Date | 2015-02-26 |
| Last Update Date | 2015-11-20 |