| NPI | 1114375912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WI 1002526) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.026058) |
| 122300000X Dentist (Licence: KS 61153) | |
| 122300000X Dentist (Licence: MN D13791) | |
| 1223G0001X Dentist, General Practice (Licence: OH 30.026058) | |
| Enumeration Date | 2016-06-02 |
| Last Update Date | 2022-02-15 |