| NPI | 1124752860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OH 30.027760) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2022-07-09 |
| Last Update Date | 2024-10-29 |