| NPI | 1518138858 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: OH 30022831) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2005019248) |
| 122300000X Dentist (Licence: IL 019.026774) | |
| Enumeration Date | 2008-03-14 |
| Last Update Date | 2015-09-23 |