| NPI | 1376233700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.028140) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH RES.004589) |
| Enumeration Date | 2023-05-09 |
| Last Update Date | 2025-07-14 |