| NPI | 1114672623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2024006712) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.028214) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: OH 30.028214) | |
| Enumeration Date | 2022-02-14 |
| Last Update Date | 2025-09-17 |