| NPI | 1245501675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS045590) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.019613) |
| Enumeration Date | 2012-01-17 |
| Last Update Date | 2026-05-01 |