| NPI | 1124582242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS042606) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30025634) |
| 122300000X Dentist (Licence: MA DN1858225) | |
| Enumeration Date | 2019-01-23 |
| Last Update Date | 2020-11-04 |