| NPI | 1972090256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NY 060468) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 12602) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-22 |
| Last Update Date | 2021-08-03 |