| NPI | 1205802691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM 1604) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 16994) |
| 1223G0001X Dentist, General Practice (Licence: AZ 3105) | |
| Enumeration Date | 2006-02-24 |
| Last Update Date | 2007-07-08 |