| NPI | 1255393237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OH 30-018163) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30-018163) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: OH 30018163) | |
| Enumeration Date | 2006-04-05 |
| Last Update Date | 2007-07-27 |