| NPI | 1497087639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: NY 053282) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NY 053282) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2010-02-12 |
| Last Update Date | 2015-08-12 |