| NPI | 1225100472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OH 17140) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9149) |
| Enumeration Date | 2006-11-14 |
| Last Update Date | 2015-01-20 |