| NPI | 1497292312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.027251) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 32653) |
| Enumeration Date | 2017-01-30 |
| Last Update Date | 2023-06-27 |