| NPI | 1093283129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IA FAC-40210) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 71.000256) |
| Enumeration Date | 2018-11-07 |
| Last Update Date | 2022-07-20 |