| NPI | 1275061582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: IL 019.031828) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.026328) |
| Enumeration Date | 2017-05-31 |
| Last Update Date | 2026-04-30 |