| NPI | 1255010351 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 14075) | 
| Additional Taxonomies | 122300000X Dentist (Licence: SC 10906) | 
| 1223G0001X Dentist, General Practice (Licence: OH 30.027307) | |
| Enumeration Date | 2023-07-17 | 
| Last Update Date | 2025-07-22 |