| NPI | 1063636686 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 9897) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 022402) |
| Enumeration Date | 2007-04-13 |
| Last Update Date | 2016-03-07 |