| NPI | 1114672623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2024006712) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH Res.OO4486) |
| Enumeration Date | 2022-02-14 |
| Last Update Date | 2024-06-13 |