| NPI | 1710339387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: NY 060382) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: FL DN25746) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-07-07 |
| Last Update Date | 2021-03-30 |