| NPI | 1073993804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: SC 8892) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.024500) |
| Enumeration Date | 2015-06-06 |
| Last Update Date | 2020-05-14 |