| NPI | 1609498534 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS044074) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 062157) |
| 1223G0001X Dentist General Practice (Licence: NY 062157) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-05-14 |
| Last Update Date | 2023-07-02 |