| NPI | 1306337670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.025848) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2018019103) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-05-22 |
| Last Update Date | 2019-08-01 |