| NPI | 1356365126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: OH 14332) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: VA VA6393) |
| 1223P0300X Dentist Periodontics (Licence: OH 14432) | |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2020-11-28 |