| NPI | 1285092320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MO 2018004249) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30024956) |
| 122300000X Dentist (Licence: MO 2018004249) | |
| Enumeration Date | 2016-02-03 |
| Last Update Date | 2020-02-01 |