| NPI | 1164509360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: NC 7437) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 7437) |
| 1223G0001X Dentist, General Practice (Licence: OH 21733) | |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2019-03-25 |