| NPI | 1558940742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 062391-01) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22ID02878600) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-04-05 |
| Last Update Date | 2022-07-11 |