| NPI | 1013170133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 26303) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30-022824) |
| Enumeration Date | 2008-07-09 |
| Last Update Date | 2011-06-22 |