| NPI | 1184277402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: OH 30.026767) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX ETN699) |
| Enumeration Date | 2019-07-17 |
| Last Update Date | 2022-09-23 |