| NPI | 1154943785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 38829) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.026136) |
| Enumeration Date | 2020-05-18 |
| Last Update Date | 2022-09-06 |