| NPI | 1104303130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 35069) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: OH 30.025520) |
| Enumeration Date | 2018-07-23 |
| Last Update Date | 2025-05-16 |