| NPI | 1205203825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901021619) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OH 30.026426) |
| Enumeration Date | 2015-08-31 |
| Last Update Date | 2021-10-22 |