| NPI | 1104493410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901600996) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH RES.004364) |
| Enumeration Date | 2021-06-06 |
| Last Update Date | 2022-10-07 |