| NPI | 1104680800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901602360) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.027750) |
| Enumeration Date | 2024-02-13 |
| Last Update Date | 2024-11-22 |