| NPI | 1801535604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IL 019-034513) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 6001056-15) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-05-31 |
| Last Update Date | 2023-11-15 |