| NPI | 1255663019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NC 8856) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OH 30-023157) |
| 1223G0001X Dentist General Practice (Licence: SC 4617) | |
| Enumeration Date | 2010-02-04 |
| Last Update Date | 2018-06-07 |