| NPI | 1508279506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 10364) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 058448) |
| 122300000X Dentist (Licence: NC 13188) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-06-06 |
| Last Update Date | 2024-05-03 |