| NPI | 1114585452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00204623) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.025820) |
| Enumeration Date | 2019-06-02 |
| Last Update Date | 2024-09-14 |