| NPI | 1447415849 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00202193) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM NMDD3013) |
| 122300000X Dentist (Licence: OH 30-023673) | |
| Enumeration Date | 2008-07-24 |
| Last Update Date | 2014-06-08 |