| NPI | 1124790241 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH RES.004594) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL14972) |
| Enumeration Date | 2021-09-28 |
| Last Update Date | 2023-07-13 |