| NPI | 1225617871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901600930) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.026432) |
| Enumeration Date | 2021-04-02 |
| Last Update Date | 2022-05-05 |