| NPI | 1407850084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00201939) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30021385) |
| Enumeration Date | 2005-06-10 |
| Last Update Date | 2015-03-15 |