| NPI | 1508152703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OH 30-023681) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH RES.3109) |
| Enumeration Date | 2011-06-26 |
| Last Update Date | 2018-12-05 |