| NPI | 1346623147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH RES.3620) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30-024466) |
| Enumeration Date | 2015-06-30 |
| Last Update Date | 2015-09-02 |