| NPI | 1922500818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist Dentist Anesthesiologist (Licence: NY 062158) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2018-03-06 |
| Last Update Date | 2022-04-23 |