| NPI | 1457589806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: KS 60693) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH PENDING) |
| Enumeration Date | 2009-06-24 |
| Last Update Date | 2022-07-21 |