| NPI | 1225185663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.022642) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS026835L) |
| 1223G0001X Dentist, General Practice (Licence: PA DS26835L) | |
| Enumeration Date | 2007-01-05 |
| Last Update Date | 2012-02-10 |