| NPI | 1669239604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 064759) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 84830) |
| Enumeration Date | 2024-03-05 |
| Last Update Date | 2026-05-26 |