| NPI | 1053576587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 3023080) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901019906) |
| Enumeration Date | 2008-07-24 |
| Last Update Date | 2022-06-18 |