| NPI | 1508399064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 059792-01) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NJ 22DI02706200) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-04-11 |
| Last Update Date | 2023-02-22 |