| NPI | 1689384836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 063945) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.027036) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-11-29 |
| Last Update Date | 2024-07-25 |