| NPI | 1407649619 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901602879) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.028040) |
| Enumeration Date | 2025-05-28 |
| Last Update Date | 2025-12-12 |