| NPI | 1386289809 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.026297) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH 57.254034) |
| Enumeration Date | 2019-11-07 |
| Last Update Date | 2023-11-20 |