| NPI | 1629601414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NY 061753) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 061753) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 1223G0001X Dentist, General Practice (Licence: NY 061753) | |
| Enumeration Date | 2020-02-19 |
| Last Update Date | 2026-04-20 |