| NPI | 1639512775 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CT 11646) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: OH 30.027111) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-04-08 |
| Last Update Date | 2024-03-09 |