| NPI | 1750904215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NJ 22D102841100) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 061719) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-05-19 |
| Last Update Date | 2023-06-17 |