| NPI | 1154807964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00205054) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.025512) |
| Enumeration Date | 2018-07-15 |
| Last Update Date | 2022-06-23 |