| NPI | 1871096883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: IL 019.031668) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 019.031668) |
| Enumeration Date | 2018-03-15 |
| Last Update Date | 2022-01-11 |