| NPI | 1184003196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.24875) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: VA 0401417766) |
| Enumeration Date | 2015-05-22 |
| Last Update Date | 2024-02-26 |