| NPI | 1508511726 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 064284-01) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 13413) |
| Enumeration Date | 2022-02-16 |
| Last Update Date | 2024-10-20 |