| NPI | 1235796988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: KY 10416) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 10416) |
| 1223P0300X Dentist, Periodontics (Licence: OH 30.025782) | |
| Enumeration Date | 2019-05-28 |
| Last Update Date | 2024-05-22 |