| NPI | 1902485485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 062592) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN26696) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-04-03 |
| Last Update Date | 2023-09-07 |