| NPI | 1609229426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 059096) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401415550) |
| 122300000X Dentist (Licence: IL 019031043) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-07-16 |
| Last Update Date | 2019-02-23 |