| NPI | 1053173294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 109770) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.027993) |
| Enumeration Date | 2024-01-24 |
| Last Update Date | 2025-06-09 |