| NPI | 1124283676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 25315) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30022764) |
| Enumeration Date | 2008-07-24 |
| Last Update Date | 2012-02-15 |