| NPI | 1053530790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.022375) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30022375) |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2021-06-16 |