| NPI | 1063675791 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OH 30022756) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WV 3830) |
| Enumeration Date | 2008-07-02 |
| Last Update Date | 2020-03-16 |