| NPI | 1215947072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30022326) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30022326) |
| 1223G0001X Dentist, General Practice (Licence: NY 052749) | |
| Enumeration Date | 2006-08-08 |
| Last Update Date | 2018-03-17 |