| NPI | 1477827293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D009203) |
| Additional Taxonomies | 122300000X Dentist (Licence: ME DEN4307) |
| 122300000X Dentist (Licence: OH 30.023636) | |
| Enumeration Date | 2012-02-24 |
| Last Update Date | 2015-05-18 |