| NPI | 1063907723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WV 4386) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH RES.003979) |
| Enumeration Date | 2018-06-26 |
| Last Update Date | 2021-03-03 |