| NPI | 1558883140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS042447) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 0190321253) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-07-14 |
| Last Update Date | 2021-05-05 |