| NPI | 1215343512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ AZ009869) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.024403) |
| 122300000X Dentist (Licence: MI 2901021330) | |
| Enumeration Date | 2014-07-08 |
| Last Update Date | 2021-02-15 |